DELIRIUM & DEMENTIA - NurseCe4Less.com · Dementia and delirium are the major causes of cognitive...

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DELIRIUM & DEMENTIA

Dana Bartlett, RN, BSN, MSN, MA

Dana Bartlett is a professional nurse and author.

His clinical experience includes 16 years of ICU

and ER experience and over 20 years of as a poison control center

information specialist. Dana has published numerous CE and journal articles,

written NCLEX material and textbook chapters, and done editing and

reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has

written widely on the subject of toxicology and was recently named a

contributing editor, toxicology section, for Critical Care Nurse journal. He is

currently employed at the Connecticut Poison Control Center and is actively

involved in lecturing and mentoring nurses, emergency medical residents and

pharmacy students.

ABSTRACT

There are many possible causes of dementia and delirium and the

more common ones are complex, such as dementia of the

Alzheimmer’s type or delirium due to drug withdrawal. This study

module will present general information about the patient with

dementia and delirium, including risk factors, treatments, and nursing

considerations. Two other relevant neurological problems, mild

cognitive impairment and pseudo-dementia, will be briefly discussed.

Detailed and extensive information about specific causes of these

diseases is outside the scope of this study.


Continuing Nursing Education Course Director & Planners:

William A. Cook, PhD, Director; Douglas Lawrence, MS, Webmaster;

Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner

Accreditation Statement:

This activity has been planned and implemented in accordance with

the policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's

Commission on Accreditation for registered nurses.

Credit Designation:

This educational activity is credited for 3.5 hours. Pharmacology

content is 15 minutes. Nurses may only claim credit commensurate

with the credit awarded for completion of this course activity.

Course Author & Planner Disclosure Policy Statements:

It is the policy of NurseCe4Less.com to ensure objectivity,

transparency, and best practice in clinical education for all continuing

nursing education (CNE) activities. All authors and course planners

participating in the planning or implementation of a CNE activity are

expected to disclose to course participants any relevant conflict of

interest that may arise.

Statement of Need:

Nurses in all practice settings that care for individuals with dementia

and delirium need to understand what defines each disorder, and

diagnostic criteria related to etiology, clinical assessment and signs

and symptoms.


Course Purpose:

To provide professional nurses with the information they need to

assess and care for patients with dementia or delirium.

Learning Objectives:

1. Identify the correct definition of dementia.

2. Identify the correct definition of delirium.

3. Identify differences between dementia and delirium.

4. Identify risk factors for dementia and delirium.

5. Identify common treatment options for dementia and delirium.

Target Audience:

Advanced Practice Registered Nurses, Registered Nurses, Licensed

Practical Nurses and Nursing Associates

Course Author & Director Disclosures:

Dana Bartlett, RN, BSN, MA, MSN, William S. Cook, PhD,

Douglas Lawrence, MS, Susan DePasquale, CGRN, MSN, FPMHNP-BC -

all have no disclosures.

Acknowledgement of Commercial Support: There is none.

Activity Review Information:

Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC.

Release Date: 10/11/2014 Termination Date: 10/11/2016

Please take time to complete the self-assessment Knowledge Questions

before reading the article. Opportunity to complete a self-assessment of

knowledge learned will be provided at the end of the course.


1. One of the defining characteristics of dementia is:

a. inability to perform activities of daily living.

b. severe agitation.

c. reversible cognitive impairment.

d. occurrence before age 50.

2. Most cases of dementia are caused by:

a. trauma and heavy metal poisoning.

b. infections and hemorrhage.

c. Alzheimer’s disease and vascular pathologies.

d. hypoxia and Parkinson’s disease.

3. Defining characteristics of delirium include:

a. movement disorders and a progressive cognitive decline.

b. attention deficits and confusion.

c. expressive aphasia and hypotension.

d. hyperthermia and depression.

4. Common causes of delirium include:

a. Parkinson’s disease and advanced age.

b. drug withdrawal and Lewy body dementia.

c. acute blood loss and frontotemporal dementia

d. drugs and dementia.

5. True or false: Dementia is an inevitable consequence of

aging.

a. True.

b. False.

6. Dementia is often misdiagnosed as:

a. depression.

b. mild cognitive impairment.

c. Alzheimer’s disease.

d. anxiety.


7. Use physical restraints with patients who have dementia or

delirium:

a. if the patient is agitated or confused.

b. when there is a significant risk for a fall.

c. if all other interventions fail and there is a serious risk of harm.

d. if the patient is likely to wander.

8. Neuropsychiatric behavior problems in patients who have

dementia:

a. are caused by an external or internal stimulus.

b. typically occur randomly and without cause.

c. only occur if patients are over-medicated.

d. happen primarily at night.

9. The use of anti-psychotics to treat patients with dementia:

a. is considered first-line therapy.

b. is most effective when used in conjunction with cholinesterase

inhibitors.

c. can reverse the progress of dementia.

d. is questionably effective and potentially dangerous

10. The drug most commonly used to treat agitation in patients

who have delirium is:

a. diazepam.

b. haloperidol.

c. galantamine.

d. bupropion.


INTRODUCTION

Dementia and delirium are the major causes of cognitive impairment

in the elderly.1 Dementia and delirium are syndromes. A syndrome is

identified by a set of symptoms and/or signs that tend to be present in

a patient at the same time. A syndrome may be caused by one or

more diseases.

Dementia and delirium are caused by a wide range of medical,

neurological and psychiatric pathologies. In some cases a specific

etiology can be confirmed by laboratory testing, specific physical

findings, or imaging studies. Most often, dementia and delirium are

clinical diagnoses. Clinicians formulating a diagnostic impression need

to understand that the relationship between dementia and delirum is

complex. There are similarities in their presentation; dementia is a

major risk factor for delirium, and delirium occurs in many patients

who have dementia.

Delirium and dementia can be acute or sub-acute, and they can be

transient and reversible or can cause permanent impairment. Both are

associated with increased morbidity and mortality. The risk of

developing dementia and/or delirium increases with advancing age,

and as the population in the US becomes older the incidence of these

pathologies will certainly increase.

Statistics

Dementia and delirium are very common, as shown in the following

statistics:

Delirium is noted in 14%-56% of elderly patients who are

hospitalized and in 40% of patients admitted to intensive care.2


Postoperative delirium is seen in approximately 5%-10% of

general surgery patients.2

Community-based studies have found a prevalence of dementia

as high as 47% in those 85 years of age and older.1

Alzheimer’s disease is the most common cause of dementia3 and

in 2013 there were approximately 5 million Americans who

suffered from Alzheimer’s disease.4

There are many causes of dementia but Alzheimer’s disease

accounts for approximately 60%-80% of all cases.5

Delirium occurs in approximately two-thirds of all adults living in

nursing homes.6

Slowing of cognitive function can occur with aging and it is not

uncommon for older people to have mild memory deficits or a

reduction in the speed with which information is processed. Old age is

a major risk factor for dementia, but advanced age itself does not

cause a decrease in cognitive and intellectual ability that interferes

with daily functioning. In brief, dementia is not an inevitable

consequence of getting old.

DEFINITION, DIAGNOSTIC CRITERIA, AND

CAUSES OF DEMENTIA

Dementia can be defined in several ways. Kane et al. (2013) defines

dementia as “. . . a clinical syndrome involving a sustained loss of

intellectual functions and memory of sufficient severity to cause

dysfunction in daily living,”1 while Seeley and Miller (2012) write that

dementia “. . . is an acquired deterioration in cognitive abilities that

impairs the successful performance of activities of daily living.”3 These

definitions emphasize key points about dementia to remember.


Firstly, the distinguishing aspect of dementia is an inability to

successfully perform the activities of daily living, caused by impaired

cognitive and intellectual capacity. Secondly, dementia is a syndrome

because there is a multitude of etiologies of dementia. Because there

is no single cause of dementia the clinical picture can be variable. The

Diagnostic and Statistical Manual of Mental Disorders V (DSM-V)

criteria for dementia, which is called major neurocognitive disorder,

are:7

A. Evidence of significant cognitive decline from a previous level of

performance in one or more cognitive domains:

Complex attention

Executive function

Language

Learning and memory

Perceptual-motor ability

Social cognition

B. The cognitive effects interfere with independence in everyday

activities. At a minimum, assistance should be required with

complex activities of daily living such as managing medications

or paying bills.

C. The cognitive effects do not occur extensively in the context of

delirium.

D. The cognitive deficits are not better explained by another mental

disorder (i.e., major depressive disorder, schizophrenia).


Dementia can be usefully divided into two categories: reversible and

irreversible. Most cases of dementia are irreversible. These dementias

slowly progress and the patient’s condition worsens over time.

Irreversible dementias are caused by: degenerative diseases of the

nervous system, infections, trauma, and vascular disorders. The most

common irreversible dementias are Alzheimer’s disease,

frontotemporal dementia, Lewy body dementia, Parkinson’s disease,

and vascular dementia. Many patients who have dementia have a

neurodegenerative and a vascular pathology.8

Table 1: Irreversible causes of dementia1

Acquired immunodeficiency syndrome

Alzheimer disease

Anoxia secondary to cardiac arrest

Arteritis

Binswanger disease

Carbon monoxide poisoning

Cerebrovascular disease, i.e., multi-infarct dementia

Craniocerebral injury, including dementia pugilistica

Creutzfeldt-Jakob disease

Huntington’s disease

Dementia associated with Lewy bodies

Frontotemporal dementia

Infections

Parkinson’s disease

Pick disease

Postencephalitic dementia

Progressive multifocal leukoencephalopathy

Progressive supranuclear palsy

Trauma

Vascular dementias


The reversible dementias are much less common than the irreversible

dementias. Irreversible dementias can be successfully treated but

finding and treating the cause does not guarantee a cure.

Table 2: Reversible or partially reversible causes of dementia1

Alcoholism

Anoxic brain injury

Autoimmune disorders

Central nervus system vasculitis

Disseminated lupus erythematous

Depression

Drugs

Heavy metal poisoning, i.e., lead, mercury

Infections

Metabolic disorders

Multiple sclerosis

Neoplasms

Normal pressure hydrocepahlus

Nutritional disorders, i.e., B6, B12 deficiency

Organic poisons, i.e., pesticides, solvents

Psychiatric disorders

Trauma

Viral infections, i.e., HIV

Medications, prescription or illicit, can also cause dementia. In most

cases the dementia caused by a drug is reversible but not always.


Table 3: Drugs that can cause dementia and delirium 1

Alcohol

Analgesics

Antiarrhythmics

Anticholinergic agents

Anticonvulsants

Antidepressants

Antihypertensives

Antipsychotics

Anxiolytics

Digoxin

H2 receptor antagonists

Non-steroidal antiiflammatories

Sedative-hypnotics

Skeletal muscle relaxers

Steroids

There is a wide range of causes of dementia, but there are similarities

in their clinical presentation.

Irreversible dementia is typically progressive, the signs and

symptoms worsening over a course of months and years. The

course is individualized with no predictability as to its pattern.

There is no usual disturbance of consciousness: the patient is

awake, alert, and responsive.

Memory loss is the most prominent cognitive disability of

dementia.

Impairment of language, visuospatial ability, calculation,

judgment, and problem solving are also common in patients who

have dementia.


Patients who have dementia often suffer from neuropsychiatric

problems including, but not limited to, agitation, apathy,

delusions, depression, disinhibition, hallucinations, insomnia, and

wandering.

As mentioned previously, the most common causes of irreversible

dementia are Alzheimer’s disease, frontotemporal dementia, Lewy body

dementia, Parkinson’s disease, and vascular dementia. Some of these

may not be familiar to many nurses and a brief description of each one

is provided below.

Alzheimer’s disease

Alzheimer’s disease is a chronic, progressive neurological disorder that

causes severe behavioral and cognitive deterioration, especially in

memory. The cause, or causes, of Alzheimer’s disease are not

completely understood. Alzheimer’s disease is probably the result of a

convergence of genetic risk factors and environmental stimuli that

produce characteristic lesions in the parietal and temporal lobes,

specifically amyloid plaques and neurofibrillary tangles. These lesions

interrupt the normal metabolism and self-repair of neurons and disrupt

communication between different areas of the brain.

The time from diagnosis to death can be as little as three years. The

signs and symptoms of Alzheimer’s disease are difficult to treat and

there is no cure.

Frontotemporal lobe dementia

Frontotemporal lobe dementia is a neuro-degenerative disease caused

by atrophy of the frontal and temporal lobe. It is a disease that is


considered clinically and genetically diverse. The hallmark signs of

frontotemporal dementia are behavioral and speech defects, such as

expressive and fluent aphasia and abnormal personal and social

behavior. In most cases the cause is unknown, however, a family

history of the disease is a strong risk factor. Frontotemporal dementia

is chronic, progressive, and there is no cure.

Lewy body dementia

Lewy body dementia is a chronic, progressive neurodegenerative

disease that is characterized by the presence of Lewy bodies,

abnormal deposits of protein that accumulate in neurons in specific

areas of the brain. The cause of Lewy body dementia is not known. It

is distinguished from other types of dementia by the Lewy bodies and

by these aspects of the clinical presentation:

1. varying levels of alertness and attention, especially reduced

responsiveness;

2. visual hallucinations, and;

3. Parkinsonian motor signs.

There appears to be some overlap of Lewy body dementia with

Alzheimer’s disease and Parkinson’s disease with dementia. Lewy

bodies are noted in some patients with Alzheimer’s disease (Lewy body

variant of Alzheimer’s disease) and in some patients with Parkinson’s

disease. Additionally, some of the signs of Parkinson’s disease with

dementia and Lewy body dementia are similar. There is no cure for

Lewy body dementia.



Parkinson’s disease is caused by chronic and progressive destruction of

dopamine-producing cells in the substantia nigra area of the brain.

Parkinson’s disease often causes dementia, but it is distinguished by

characteristic motor symptoms such as bradykinesia (slowness of

movements), gait disturbances, rigidity, and tremor.

Approximately 10% of all cases of Parkinson’s can be clearly identified

as having a genetic cause, but most cases are considered to be caused

by a convergence of genetic risk factors and environmental stimuli.

There is no cure for Parkinson’s disease but there is effective

symptomatic treatment and the progression of the disease can be

delayed.

Vascular dementia

Vascular dementia is the second most common cause of dementia and

it often co-exists with Alzheimer’s disease. Vascular dementia is not a

single disease; it is a group of syndromes that are caused by vascular

pathologies, such as:

cerebral infarct

cerebral hemorrhage

embolic and/or thrombotic obstructions (i.e., stroke)

various types of lesions like lacunar lesions

There are many causes of vascular dementia, and atherosclerosis,

diabetes, hypercholesterolemia, hypertension, and smoking are

significant risk factors.


DEFINITION, DIAGNOSTIC CRITERIA, AND

CAUSES OF DELIRIUM

Delirium is an acute change in mental status characterized by

confusion and attention deficits.2,9 As with dementia, delirium is a

syndrome, there are a multitude of causes, and the clinical

presentation can vary. Delirium is usually transient and reversible, but

delirium can persist for hours or days (acute) or weeks or months

(persistent), and it is associated with high rates of morbidity and

mortality.

The Fifth Edition of the Diagnostic and Statistical Manual of Mental

Disorders (DSM-V) criteria for a diagnosis of delirium are:10

1. A disturbance in attention, i.e., reduced ability to direct, focus,

sustain, and shift attention and disturbance in awareness, i.e.,

reduced orientation to the environment.

2. The disturbance develops over a short period of time, usually

hours to a few days. It represents a change from baseline

attention and awareness, and tends to fluctuate in severity

during the course of a day.

3. An additional disturbance in cognition such as memory deficit,

disorientation, language, visuospatial ability, or perception.

4. The disturbances are not better explained by another

preexisting, established, or evolving neurocognitive disorder and

do not occur in the context of a severely reduced level of

arousal, such as coma.


5. There is evidence from the history, physical examination, or

laboratory findings, that the disturbance is a direct

physiological consequence of another medical condition, such as,

substance intoxication, or withdrawal from a drug of abuse or to

a medication, exposure to a toxin, or due to multiple etiologies.

Delirium is a sudden change in cognition. It develops over a short

period and it fluctuates in severity; and the most prominent feature of

delirium is the change that occurs in attention and awareness. The

DSM-V and other sources note that delirium can be manifested by

hyperactive, hypoactive, or mixed states.

Hyperactive delirium is characterized by a hyperactive level of

psychomotor activity, and it is seen in patients who are intoxicated or

in withdrawal from drugs such as amphetamine or phencyclidine.

Hypoactive delirium is characterized by a decreased level of

psychomotor activity, and the patient is lethargic and sluggish.

Whereas, mixed state delirium is characterized by alternating periods

of agitation and sedation.

As with dementia, there are many causes of delirium that may

influence a patient’s health condition. Drugs and medications are an

important and common cause of delirium. Dementia is also a very

common cause of delirium. Delirium can happen to any patient, but it

is more common in the elderly. Causes of delirium are listed in Table 4

below.


Table 4: Common causes of delirium1,11

Acute blood loss

Acute myocardial infarction

Acute psychoses

Azotemia

Congestive heart failure

Decreased cardiac output

Decreased sensory input

Dehydration

Dementia

Drugs

Drug overdose

Drug withdrawal

Dehydration

Fecal impaction

Intoxication

Hypercarbia

Hypo- or hyperglycemia

Hyponatremia

Hypo- or hyperthermia

Hypoxia

Infections

Metabolic disorders


Stroke (small cortical)

Urinary retention

It is not clear if advanced age itself is a risk factor for delirium.

However, the elderly patient population often has greater exposure to

identified risk factors for delirium: bladder catheterization, decreased

ability to metabolize and eliminate medications, dementia, fracture,


hearing impairment, immobility, inadequate or excessive use of

analgesics or sedatives, malnutrition, multiple medications, pre-

existing dementia, sensory deprivation, status-post anesthesia and

surgery, underlying medical or neurologic illnesses, use of physical

restraints, and visual impairment.1,6,10

Delirium is often misdiagnosed2,10 and it may be mistaken for

dementia, depression, another psychiatric disorder, or attributed to

“old age.” This under-recognition can delay treatment, and it can also

prolong the duration of delirium and expose the patient to permanent

neurological damage.6

MILD COGNITIVE IMPAIRMENT AND PSEUDO-DEMENTIA

Mild cognitive impairment (MCI) and pseudo-dementia should also be

mentioned when discussing dementia. Individuals who have MCI or

pseudo-dementia can often develop dementia. MCI is often

overlooked; and, pseudo-dementia is often misdiagnosed as dementia.

Mild cognitive impairment is a term used to describe cognitive deficits

that are not considered to be a normal part of aging but do not fit the

diagnostic criteria for dementia.7,12 There are differences in the

diagnostic criteria for MCI and these criteria are not precise, but MCI is

generally considered to be an intermediate state between normal

cognitive functioning and dementia. Patients who have MCI have

memory deficits and occasionally they have subtle defects in other

cognitive abilities, but they have normal executive functioning and

they do not have difficulties performing activities of daily living.7,11,13


The patient who has MCI is aware of the change in his or her memory,

unlike the person who has dementia. Mild cognitive impairment may

be temporary13 but approximately 15% of people who have MCI will

develop dementia.14

Pseudo-dementia is a descriptive term for a clinical presentation that

closely mimics dementia, but is usually caused by depression7 and

occasionally by other psychiatric disorders.15 Depression in the elderly

can cause many of the cognitive defects that are common to dementia.

Dementia can produce depressive signs and symptoms16 such that a

misdiagnosis is relatively common. Some key differences between

dementia and depression are:7

Depression has an abrupt onset but the onset of dementia is

slow.

Dementia progresses while depression plateaus.

Patients who are depressed often know they are depressed and

will complain of their problem. Patients who have dementia are

seldom aware of their condition.

The affect and emotions of people who have dementia are

variable. People who are depressed have a depressed affect and

mood.

Imaging tests, laboratory tests, and the neurological exam of a

patient who has dementia will often be abnormal; this is not the

case for patients who are depressed.

ASSESSMENT OF DEMENTIA

Assessment and the diagnosing of dementia can be quite challenging.

One of the primary problems in assessment is that the ptient is often

an unreliable source of information. Confirmation of the diagnosis of


dementia using imaging studies, laboratory tests, and/or specific

physical findings may not be possible. Also, some patients may have

more than one cause of dementia. The diagnostic process is time

consuming, and it is not uncommon for dementia to be misdiagnosed.5

The incidence of a missed diagnosis of dementia has been reported to

be as high as 50%-80%, depending on the severity of the case and

who is doing the assessment.17 The specific diagnostic approach, i.e.,

what tests should be ordered, will differ depending on the suspected

cause of dementia. The assessment process outlined below can be

applied to any situation in which dementia may be present.

Vital signs

Assessment of the airway, breathing, and circulation (ABCs) and body

temperature is always the first step of a patient assessment.

Abnormalities of blood pressure, pulse, and temperature, etc., can

provide valuable indicators about the source of dementia. For example,

hypothermia can indicate the presence of hypothyroidism and

hypertension can indicate the presence of vascular dementia.

History

The events in the patient’s life prior to the assessment should be

reviewed, either by speaking to the patient, family members, friends,

or caretakers. The reviewer should ask specific questions about

behavior, changes in social circumstances, daily activities, elimination

patterns, food and fluid intake, and mood. It is important to learn

whether there have been any recent events such as an accident,

illness, trauma, or surgery that could be a cause of delirium.


Family or significant other interview

A careful interview of family members or significant others and

caretakers are a necessary part of patient evaluation because the

patient who has dementia will seldom be aware of the changes in

cognition and memory. The interviewer should ask specific questions

about the patient’s day-to-day life:

Has the patient been agitated, disruptive, or verbally aggressive?

Has there been wandering behavior or dangerous driving?

Has the patient had difficulty wth sleeping?

Has the patient’s personal hygiene deteriorated or has he or she

been incontinent?

Galvin et al. (2006) found that the following eight question interview

was sensitive and specific for detecting dementia and cognitive

impairment.18 The following should be investigated: Has the patient

shown any of the following deficits or behaviors?

Problems with judgment

Reduced interest in activities or hobbies

Repeating questions, stories, or statements

Trouble learning how to use an appliance or tool

Forgetting what month or year it is

Unable to handle simple financial affairs

Forgetting appointments

Consistent problems with memory and/or thinking

Medical and surgical history

The patient’s medical and surgical history should be be carefully

reviewed. This review should include the medical history of the

patient’s immediate family, i.e., parents and siblings. Asking about


alcohol or drug abuse can be uncomfortable but it should be done as

often times as is necessary. Additionally, it is often helpful to review

the patient’s history of alcohol or drug abuse with someone other than

the patient.

Medication history

When reviewing the patient’s health history, a current list of the

prescription medications the patient is taking should be obtained and

verified to know whether new medications have recently been

prescribed or doses have been changed. An inquiry should be made

about the use of over-the-counter and/or herbal medications. It should

also be determined if the patient has been taking his or her

medications as prescribed. There may have been an inadvertent or

intentional overdose, the patient may have been skipping doses, or he

or she may have simply stopped taking a prescribed medication.

Physical assessment

A comprehensive physical examination should be performed. The

findings may be equivocal and/or non-specific. But the presence of

some physical findings and the absence of others can help the

clinician decide which diagnostic tests should be done and suggest the

cause of the dementia. For example, bradykinesia and gait

disturbances are characteristic of Parkinson’s disease, the presence of

papilledema suggests that the patient may a brain tumor or a subdural

hematoma, and myoclonus can indicate the presence of human

immunodeficiency virus (HIV)-related dementia.8


Laboratory tests, imaging studies, and other diagnostic tools

There are no laboratory tests, imaging studies, or other diagnostic

tools that should be routinely performed for every patient who is

suspected of having dementia.5 The physical examination and history

taking should determine what is needed, and it is important to focus

diagnostic efforts in order to avoid unnecessary procedures and delays

in making the diagnosis.

Laboratory tests that are helpful when determining the cause or

presence of dementia include complete blood count (CBC), blood urea

nitrogen (BUN) and creatinine, serum calcium and phosphorus, pulse

oximetry, serum glucose, serum electrolytes, liver function tests,

thyroid studies, vitamin B12 level, 12-lead ECG, and (possibly) testing

for HIV antibodies. The use of neuro-imaging studies such as

computerized tomography (CT) and magnetic resonance imaging

(MRI) can be used to determine the specific type of dementia, to

evaluate the progress of neurological damage, and possibly predict

who will develop dementia.19,20 For example, medial temporal lobe

atrophy is common in patients with dementia, but it is usually more

pronounced, and the pattern of injury different, in patients who have

Alzheimer’s disease; and, cerebral infarcts may be seen in patients

who have vascular dementia.19

DEMENTIA: NEUROLOGICAL AND PSYCHIATRIC EVALUATION

A careful assessment of the patient’s neurological and psychiatric

status is the crucial part of the evaluation for the presence of

dementia. There is much information that can be acquired by simple

observation. When the clinician is examining or interviewing the

patient, its important to pay special attention to:8


Alertness/level of consciousness:

Whether the patient is paying attention and responding to their

surroundings

Aphasia:

Inability to express or understand language, spoken or written

Apraxia:

Inability to perform physical tasks that the patient should have

the capability of doing

Behavior:

Erratic or inappropriate behavior in the patient, observed or

reported

General appearance

Memory:

How well the patient retains and recalls information

Mood:

Unexplained mood swings in the patient, observed or reported

Orientation:

Whether the patient knows the date and time

Thought process:

Organized or disorganized thinking

The clinician should also carefully observe the patient for:1

Executive functioning, i.e., planning, weighing alternatives,

coordination of mental faculties for accomplishing tasks

General appearance and behavior

Insight and judgment

Memory, short-term and long-term

Language

Level of consciousness


Orientation

Language

Mood and affect

Thought content

Visuospatial functions, i.e., how well the patient analyzes and

understands space in several dimensions

Neurological and psychiatric functioning can also be assessed by using

neuropsychological testing and standardized screening tests.

Neuropsychological testing is a broad term that refers to tests that are

designed to assess a single neurological function such as memory,

intelligence, or visuospatial ability. For example, memory can be

tested using the Constructional Praxis Test, and visuospatial ability can

be tested using the clock test.

Although neuropsychological tests are lengthy and complex, they can

be helpful when the initial assessment shows a cognitive deficit but the

specific problem causing the cognitive deficit is not obvious. These

tests are considered to have a relatively high sensitivity and specificity

for detecting dementia,5 and can be useful in differentiating dementia

from depression.1

Standardized screening tests can be helpful to assess for the presence

and severity of dementia, but it should be remembered that these are

used for screening; they are not diagnostic. Four screening tests that

are commonly used are the Mini-Mental State Examination (MMSE),

the Mini-Cog, The Clinical Dementia Rating (CDR) scale and the

Montreal Cognitive Assessment (MOCA). There are many other

assessment tests or tools and a full discussion of each one and their


limits, strengths, and how and when they should be used is beyond

the scope of this study. A more indepth study on dementia screening

tests is available through the 2014 review by Yokomizo et al.17 and a

2013 review by Lin et al.20

Mini-mental status exam

The Mini-Mental Status Exam (MMSE) is commonly used. It can be

done relatively quickly, and it is the most widely studied of the

cognitive screening tests.19 The test is not considered to be sensitive

for diagnosing mild dementia and performance may be affected by age

and level of education.5 It involves performance of the following

tasks:

1. What is the date: (year)(season)(date)(day)(month) - 5 points

2. Where are we: (state)(county)(town)(hospital)(floor) - 5 points

3. Name three objects:

Name three objects and then ask the patient to repeat them.

Give one point for each correct answer. Repeat them until he or

she learns all three. Count and record the number of trials. The

first repetition determines the score, but if the patient cannot

learn the words after six trials then recall cannot be meaningfully

tested. Maximum score - 3 points.

4. Serial 7s:

Ask the patient to count backwards in increments of 7, starting

with the number 100. One point for each correct answer; stop

after five answers. Alternatively, spell WORLD backwards, one

point for each letter in correct order. Maximum score - 5 points.


5. Ask for recall of the three objects repeated (above in #3):

one point for each correct. Maximum score - 3 points.

6. Show and ask patient to name a pencil and wrist watch - 2 points.

7. Repeat the following: "No ifs, ands, or buts." Allow only one trial -

1 point.

8. Follow a three stage command, "Take a paper in your right hand,

fold it in half, and put it on the floor." Score one point for each

task executed. Maximum score - 3 points.

9. On a blank piece of paper write "close your eyes." Then ask the

patient to read and do what it says - 1 point.

10. Give the patient a blank piece of paper and ask him or her to

write a sentence. The sentence must contain a noun and verb and

be sensible - 1 point.

11. Ask the patient to copy a design (i.e., intersecting pentagons). All

10 angles must be present and two must intersect – 1 point.

The maximum score on the MMSE is 30 points. A score of less than 24

points is usually considered to be suggestive of dementia or delirium.5

Mini-cog test

The Mini-Cog test requires the patient to: 1) draw a clock with the

numbers in correct sequence and the clock hands correctly indicating

the current time; and, 2) perform an un-cued recall of three objects.


The names of the three objects (i.e., banana, car, dog) are given to

the patient and he or she is then asked to repeat them. After that, the

patient is asked to draw the clock and when that task has been

completed, he or she is asked to tell the interviewer the names of the

three objects. Each correctly recalled word is worth one point and the

clock is considered normal if the time is correct and the clock is grossly

normal.

Dementia is present if the score is 0 or if the patient recalls 1-2 words

and the clock is abnormal. If the patient recalls 1-2 words and the

clock is normal or if the patient recalls all 3 words, there is no

dementia. The Mini-Cog takes approximately three minutes to

administer, and it is considered to be very sensitive for detecting

dementia.5,21

Clinical dementia rating

The clinical dementia rating (CDR) was designed to assess the severity

of Alzheimer’s disease. It is rather lengthy to administer and it

depends to a degree on the subjective observations of the test

administrator, but it has been shown to be valid and sensitive.5 The

patient’s abilities in the following areas are assessed.

Community affairs

Home and hobbies

Judgment

Memory

Orientation

Problem solving


The patient is judged on her or his abilities and performances in these

areas as follows:

0 = None

0.5 = Very mild

1 = Mild

2 = Moderate

3 = Severe

The ratings and interpretations are:

0 = Normal

0.5 to 4 = Questionable cognitive impairment

4.5 to 9 = Mild dementia

9.5 to 15.5 = Moderate dementia

≥ 16 = Severe dementia

Montreal cognitive assessment (MOCA)

The Montreal Cognitive Assessment (MOCA) has been shown to be a

useful screening tool for detecting mild levels of cognitive impairment

in patients who have Alzheimer’s disease, 22,23 for identifying people

with cognitive impairment who are at risk for developing dementia,24

and identifying patients who have dementia.26,27 The patient is

assessed in ten areas of cognitive ability, i.e., attention, memory, and

sentence repetition, and the test takes approximately 10 minutes to

administer. A complete example of the MOCA will not be presented

here as it is quite lengthy; the reader is referred to the following

website for complete information on the MOCA at

http://www.mocatest.org/.


ASSESSMENT OF DELIRIUM

In many cases delirium is a clinical diagnosis that cannot be confirmed

by imaging studies, laboratory tests, or specific physical findings and

determining whether the patient does, or does not, have delirium will

depend on thorough history taking and patient assessment. The

assessment process outlined below can be applied to any situation in

which delirium may be present.

Vital signs

Assessment of the airway, breathing, and circulation (The ABCs), and

body temperature is always the first step of a patient assessment.

Hypo- and hyperthermia, hypoxia, hyper- and hypotension,

bradycardia, tachycardia, respiratory depression and tachypnea can be

signs of causes of delirium. Some causes of delirium include blood

loss, congestive heart failure, dehydration, drug overdose, infection,

and myocardial infarction.

History

The events in the patient’s life prior to the onset of delirium should be

reviewed, either by speaking to the patient, family members, friends,

or caretakers. The clinician should ask specific questions about

behavior, changes in social circumstances, daily activities, elimination

patterns, food and fluid intake, and mood. Its important to learn

whether there have been any recent events such as an accident,

illness, trauma, or surgery that could be a cause of delirium.


Medical and surgical history

The patient’s medical and surgical history should be carefully

reviewed. This review should include the medical history of the

patient’s immediate family, i.e., parents and siblings. Similar to the

history taking with dementia, the history should include a thorough

investigation into the patient’s use or abuse of substances. Since he or

she may not be forthcoming or unable to inform the interviewer about

the history of substance abuse, it may be necessary to ask someone

other than the patient about the patient’s use of alcohol and/or illicit

drugs.

Medication history

A current list of the prescription medications the patient is taking and

verification of new medications recently prescribed or changes in

dosing is important. The clinician should inquire about the use of over-

the-counter and/or herbal medications. It is important to determine if

the patient has been taking his or her medications as prescribed.

There may have been an inadvertent or intentional overdose, the

patient may have been skipping doses, or he or she may have simply

stopped taking a prescribed medication.

Physical assessment

A physical examination can be difficult or impossible to perform if the

patient is agitated, confused, or uncooperative. If it is not possible to

do a complete physical examination then the clinician should do a

partial examination. An examination should be done in stages and as

much information gathered as possible by observing the patient.


Findings from a physical examination in these situations may be

equivocal. However, the presence of some physical findings and the

absence of others can help the clinician decide which diagnostic tests

should be done and can suggest the cause of the delirium. For

example, the patient who has had a stroke may have hemiparesis or a

patient who is dehydrated will have dry mucous membranes and

decreased skin turgor.

Laboratory testing, imaging studies, and other diagnostic tools

There are no laboratory tests, imaging studies, or other diagnostic

tools that should be routinely performed for every patient who is

suspected of having delirium. The physical examination and history

taking should determine what is needed, and it is important to focus

diagnostic efforts in order to avoid unnecessary procedures and delays

in making the diagnosis. Tests that are helpful when assessing for the

presence of delirium are the CBC, BUN, creatinine, serum calcium,

electrolytes, and glucose, pulse oximetry, 12-lead ECG, and

urinalysis.9

DELIRIUM: NEUROLOGICAL AND PSYCHIATRIC EVALUATION

As with the physical examination, a complete neurological and

psychiatric evaluation may not be possible if the patient is agitated,

confused, or uncooperative. When evaluating a patient for the pesence

of delirium, carefully observe these areas of cognition and behavior:1

Executive functioning, i.e., planning, weighing alternatives

General appearance and behavior

Insight and judgment

Memory, short-term and long-term

Language


Level of consciousness

Orientation

Language

Mood and affect

Thought content

Visuospatial functions, i.e., how well the patient analyzes and

understands space in several dimensions

The signs and symptoms of delirium include:1,11

Agitation

Anxiety

Apathy

Delusions

Difficulty with language and speech

Disorientation

Distractability

Drowsiness

Dysarthria

Dysphasia

Emotional lability

Flight of ideas

Fluctuating level of consciousness

Hallucinations

Illusions

Inability to concentrate or focus

Memory loss

Restlessness

Sleep disturbances

Tremor


Standardized screening tests can be used to detect delirium. One of

the oldest and most commonly used in the Confusion Assessment

Method (CAM).28 The CAM has been shown to be accurate and

reliable.29,30 It is easy to administer and it can be used in a wide

variety of clinical situations.29,30 It has two parts: the first is an

assessment tool that is used to detect cognitive impairment and the

second is a short screening test that is used to distinguish delirium

from dementia. Part two is presented here, in Table 5. The diagnosis of

delirium by CAM requires the presence of features 1 and 2 and either 3

or 4.30

Table 5: The CAM Screening Test Part 2

1. Acute Onset and fluctuating course

Is there evidence of an acute change in mental status from the

patient’s baseline?

Did the abnormal behavior fluctuate during the day, i.e., tend to come

and go, or increase and decrease in severity)?

2. Inattention

Did the patient have difficulty focusing attention (i.e., being easily

distractible) or have difficulty keeping track of what was being said?

3. Disorganized thinking

Was the patient’s thinking disorganized or incoherent? Did he or she

have rambling or irrelevant conversation, unclear or illogical flow of

ideas, or unpredictable switching from subject to subject?

4. Altered level of consciousness

How would patient’s level of consciousness be rated? Alert

(normal), vigilant (hyper-alert), lethargic (drowsy, easily aroused),

stuporous (difficult to arouse), or coma (un-arousable). If the patient’s

level of consciousness is anything other than alert, that should be

considered a positive score.


NURSING CARE OF THE PATIENT WITH DEMENTIA

Nursing care and treatment of the patient who has dementia should

focus on:

Communication

Neuropsychiatric behavioral issues

Safety and comfort

Pain Control

Medication used to treat dementia

Communication

The patient who has Alzheimer’s disease, vascular dementia, or any

pathology that causes dementia will have problems in using and

understanding langage. He or she may have difficulty understanding

what is said, expressing ideas and emotions, and responding

appropriately.31 Hearing and speech impairments may be present and

depression may negatively influence the patient’s desire to

communicate.

Limitations of the patient with dementia does not mean the patient

needs to be isolated or that the nurse cannot have clear and

meaningful communication with the patient. The keys to overcoming

limitations are assessment and adjustment. The nurse caring for the

dementia patient needs to assess the patient’s communication abilities

and needs and then adjust their communication style. If the nurse can

do this, the interactions between the nurse and the patient will be

effective and satisfying. This is done on an individual basis but there

are some simple principles the nurse should always keep in mind when

communicating with a patient who has dementia.


Communication problems associated with dementia do not

correspond to a loss of self-identity and studies show that the

personality endures despite these communication difficulties.32

When the patient’s self-identity is acknowledged by caregivers,

disruptive and combative behavior is often dissipated. The

challenge for caregivers is to discover the patient’s self-identity.

Families and caregivers develop effective personalized

communication patterns with patients 33 and it can be very

helpful to ask them how they communicate with the patient.

Reality orientation is a helpful communication strategy. It

involves constant, repetitive verbal and visual clues to keep the

patient oriented. This technique can improve functional abilities

in patients who have dementia.34 Potential scenarios would be

that the nurse introduces themself each time they talk to the

patient, points to calendars and clocks frequently in

conversation, and talks about current events and the plans for

the day.

Speaking clearly and slowly is important in the faciliation of

meaningful and successful conversation with the patient with

dementia. The nurse should remember to make eye contact and

use short sentences. Waiting for responses and not answering

for the patient is another helpful strategy; and, the nurse should

avoid finishing sentences for the patient or interrupting them. If

the patient cannot answer or respond correctly at first, the nurse

should try again. Being aware of one’s tone and volume of voice

and of body language is important.


Minimizing distractions when communicating with the patient

with dementia and avoiding several conversations at the same

time will help the patient’s effort to communicate.31 The

Alzheimer’s Association publishes a guideline on communicating

with patients who have dementia that outlines some of these

strategies. These may be located at the following website:

https://www.alz.org/national/documents/brochure_communicati

on.pdf.

Neuropsychiatric behavioral problems

Neuropsychiatric behavior problems are a common and serious

complication of dementia.35,36 Agitation, aggression, anxiety, apathy,

delusions, depression, disinhibition, hallucinations, sleep disturbances,

and wandering occur quite often and they are disturbing for patients

and caregivers. They are also potentially dangerous and, if not

properly managed, can increase the incidence of morbidity and

mortality and increase length of hospital stay.

It is often assumed that these problems are simply part of dementia

and dementia does contribute to their development. However, the

cause of agitation, aggression, inappropriate actions and speech, etc.,

is almost always internal and/or external stimuli that are not obvious

to family members, caregivers, and health care professionals.35,37 The

patient who has dementia frequently has cognitive deficits that affect

his or her ability to cope, communicate, and provide self-care, and

neuropsychiatric behavior problems are simply a response to stress.

Its important for the caregiver or clinician to evaluate stressors and

the patient’s response to stressors. Considering neuropsychiatric

https://www.alz.org/national/documents/brochure_communication.pdf

https://www.alz.org/national/documents/brochure_communication.pdf


behavior problems as “normal” for a patient who has dementia is in

one sense treating the patient as less than whole.

It is recommended that behavioral and environmental approaches

should be used to treat neuropsychiatric behavior problems.35

Psychotropic medications should only be used in these situations if:

non-pharmacologic interventions have failed;

the patient has major depression with or without suicidal

ideation;

the patient has a psychosis that is causing great harm or has the

potential to do so;

the patient is very aggressive and may harm him- or herself or

others.35

DICE method

The optimal approach to neuropsychiatric behavior problems can be

summarized as making every effort to understand the situation from

the patient’s point of view. A recommended method is the DICE

approach: Describe, Investigate, Create and Evaluate.35 This is a

systematic way of identifying and treating neuropsychiatric behavior

problems that operates with the assumption that such behavior

problems are caused by a stressor that can be identified and

corrected, and that these issues can be solved with creativity and

patience. The steps in the DICE method is further explained below.

Describe

In the first step of the DICE method the clinician is exploring such

questions as:


When is the patient agitated and where is he or she when this

behavior is happening?

Who was the patient interacting with or near to when the

agitation occured?

What are the environmental conditions, the time of day?

What was the patient doing immediately before the agitation

began?

Is the patient complaining and if so, about what?

Investigate

In this step the clinician is looking for cause, by investigating such

questions as:

Was the patient recently given a medication or is he or she

scheduled for a dose?

Was the patient recently started on a medication?

Has the patient been incontinent or could he or she be in pain?

Has the patient’s daily activity schedule been changed or his or

her sleep pattern been disrupted?

What are the patient’s vital signs?

When performing this investigation it is important to remember that

many people who have dementia are elderly and have chonic medical

problems. Neuropsychiatric behavioral problems are often caused by

emotional or psychological stress, but the possibility of an acute illness

or exacerbation of an existing one should always be considered.

Create

Creating a treatment plan should be a collaborative effort between

nurses, other healthcare professionals and, if they are involved in day-


to-day care, the family members. The clinician needs to focus on the

behavior that is problematic at the time, but also on root cause and

prevention. Strategies for the two can be different. The patient who is

agitated may need to be in a place that is quiet and away from others

- an immediate solution - but underlying causes such as over-

stimulation and pain need to be addressed.

Evaluate

In this final step, the clinican is evaluating the strategy in terms of

negative and positive consequences and how easy it was to apply.

SAFETY AND COMFORT OF THE PATIENT WITH DEMENTIA

Safety and comfort are very important areas of care. The patient who

has dementia has a decreased capacity for decision making and may

also have limited physical capabilities. Those factors increase the risk

for accidents, errors in judgment, falls, and other forms of harm.

Discomfort is a common sourcce of behavioral problems for the patient

who has dementia. He or she may be unable to communicate about

discomfort or take actions to relieve discomfort, and this can lead to

behavioral problems such as agitation or wandering. Assessment and

re-assessment of the patient and his or her environment must be done

frequently, and the clinician should always be evaluating whether the

patient is safe and comfortable.

Pain control

Pain is very common in patients who have dementia.38,39 Patients who

have dementia do not experience any less pain than older adults

without dementia, but assessment for pain in this patient population is


challenging. Patients who have dementia may not interpret sensations

as painful, have difficulty recalling pain in the recent past, and may be

unable to tell someone about their pain.40 In addition, the patient who

has dementia may be prescribed analgesics, anti-psychotics, or other

medications that can blunt their response to pain. Untreated pain can

cause behavioral problems and psychological distress39, and untreated

pain in any patient is unacceptable.

Assessment for the presence of pain and evaluating the success of

treatments for pain depends in large part on self-reporting: the patient

will tell us how much pain he or she is having and if the interventions

provided reflief. However, for the patient who has dementia this is

seldom an option. Nurses and other healthcare professionals will need

to use professional judgement and an assessment tool.

There are many pain assessment tools available, but it is not clear

which ones are best for this clinical application .39 Corbett et al.

(2014) in a recent review noted that the Mobilization-Observation-

Behavior-Intensity-Dementia-2 (MOBID-2) pain assessment tool is “ . .

arguably the most promising of recently evaluated tools . . . “ It was

very reliable for detecting the presence of pain in patients who have

dementia and could also be used to assess the response to pain

treatments.39 The MOBID-2 uses: 41

1. The patient’s observed responses (facial expression, aversive or

defensive behavior, and noises indicating the presence of pain)

to five simple physical tasks, i.e., stretching both arms towards

the head;


2. Observations by the nurse or other caregiver of patient behavior

during normal daily actvities that may indicate the presence of

pain.

Medications used to treat dementia

The drugs most commonly used to treat dementia are the

cholinesterase inhibitors.42 The four cholinesterase inhibitors currently

available are donepezil (Aricept®), galantamine (Razadyne®),

rivastigmine (Exelon®), and tacrine (tacrine is no longer used in the

US because it can cause severe side effects).42 These drugs inhibit the

activity of cholinesterase at the synaptic cleft and increasing

cholinergic transmission. Patients who have Alzheimer’s disease have a

decreased cerebral synthesis of acetylcholine, but the cholinesterase

inhibitors are used to treat vascular dementia, Lewy body disease,

frontotemporal dementia, and other forms of dementia.

The cholinesterase inhibitors can produce a mild improvement in

cognition and increase the ability to perform activities of daily living,

and they may delay progression of cognitive defects.1,37,42 The long-

term benefits of the use of cholinesterase inhibitors for patients who

have dementia is still being determined. It is not known which patients

who have dementia should be prescribed these drugs and the optimum

duration of therapy.42 Regardless, most sources recommend a trial

period of cholinesterase inhibitors and donepezil, galantamine, or

rivastigmine; and, they appear to be equally effective.42 The dose

should be slowly titrated and at the end of eight weeks of the

maximum dose the patient should be re-assessed. If there is no

improvement, the drug should be stopped.42


Donepezil, galantamine, and rivastigmine are available as oral tablets,

solution, sustained-release capsules, and transdermal patch. Because

of their mechanism of action, gastrointestinal effects such as diarrhea,

nausea, and vomiting are very common. Agitation, ataxia, dizziness,

headache are also common adverse effects.

Memantine (Namenda®) is an N-methyl-D-aspartate (NMDA) receptor

antagonist. N-methyl-D-aspartate is a neurotransmitter that mimics

the action of glutamate, a major excitatory neurotransmitter.

Memantine has a labeled use for the treatment of moderate to severe

dementia associated with Alzheimer’s disease and an unlabeled use for

the treatment of mild to moderate vascular dementia. Used alone or

with cholinesterase inhibitors, memantine helps improve cognition and

performance of activities of daily living, and it may slow progression of

the disease.43 Common adverse reactions effects of memantine include

confusion, dizziness, and headache. The drug is available as oral

tablets, solution, and extended-release capsules.

Anti-psychotics should be avoided.1 The evidence of their effectiveness

for treating patients who have dementia is very limited44,45 and there

is clear evidence that these drugs increase the risk of stroke and

mortality in elderly patients with dementia.37,46 Additionally, anti-

depressants and hypnotics appear to have limited effectiveness for

patients with dementia.37 Other medications that have been used to

treat patients who have dementia, either for symptomatic relief or as

preventative measures include: estrogen, folic acid, gingko biloba,

non-steroidal anti-inflammatories, selegiline, statins, vitamin B6,

vitamin B12, and vitamin E.1,43 At this time, there is no evidence that

any of these drugs are effective.1,43


Other therapies and interventions

Cognitive rehabilitation, formalized exercise programs, and

occupational therapy are relatively risk-free interventions that have

been shown to be of benefit for patients who have dementia.43

NURSING CARE OF THE PATIENT WITH DELIRIUM

Delirium is considered to be a medical emergency.2 Therapies and

interventions that would be appropriate when treating most patients

who have delirium would be:9,47

Hydration

Assess the level of stimulation. Under- and over-stimulation can

be a problem for patients who have delirium.

Re-orientation techniques

Bedside sitter

If possible and if it helps, close contact with a family member or

someone familiar to the patient is encouraged.

Make sure the patient has his or her corrective lenses and/or

hearing aid, if they use these.

Maintain normal sleep patterns.

Assess for and treat pain.

Physical restraints should not be used unless other interventions have

failed and there is risk to the patient or others.9,47,48 The standard

pharmacological therapy for treating patients who have delirium and

are agitated is haloperidol.9 Haloperdiol and other antipsychotics, i.e.,

aripiprazole, olanzapine, quetiapine, and risperidone have all been

shown to be effective in treating delirium, but the effect is modest and

when they are compared there is no evidence that any one of the

antipsychotics offers a significant advantage.49-51 Drowsiness and


extrapyramidal effects are common adverse effects of the

antipsychotics.

SUMMARY

Dementia and delirium are neurological disorders that cause signficant

cognitive impairment and increase the risk of morbidity and mortality.

These diseases can be difficult to detect and diagnose. Some cases of

dementia and many cases of delirium are reversible, but dementia is

most often chronic, progressive, and cannot be cured; and, the

dementias and deliriums that are considered reversible may result in

serious complications. The most common cause of dementia is

Alzheimer’s disease. Medications and dementia appear to be the most

common causes of delirium.

Advanced age itself is not a cause of either disease, but the elderly do

have a high risk for developing dementia and delirium; and, as the US

population continues to get older, the incidences of dementia and

delirium are likely to increase. Treatment of dementia and delirium is

primarily symptomatic and supportive unless there is a clearly

identified etiology. Primary concerns when providing nursing care for

the patient who has either dementia or delirium are: monitoring of

vitals signs, behavioral and environmental interventions, safety and

comfort, pain control, and safe administration of medications.

Please take time to help the NURSECE4LESS.COM course planners evaluate

nursing knowledge needs met following completion of this course by

completing the self-assessment Knowledge Questions after reading the

article. Correct Answers, pg. 48.


1. One of the defining characteristics of dementia is:

a. inability to perform activities of daily living.

b. severe agitation.

c. reversible cognitive impairment.

d. occurrence before age 50.

2. Most cases of dementia are caused by:

a. trauma and heavy metal poisoning.

b. infections and hemorrhage.

c. Alzheimer’s disease and vascular pathologies.

d. hypoxia and Parkinson’s disease.

3. Defining characteristics of delirium include:

a. Movement disorders and a progressive cognitive decline.

b. Attention deficits and confusion.

c. Expressive aphasia and hypotension.

d. Hyperthermia and depression.

4. Common causes of delirium include:

a. Parkinson’s disease and advanced age.

b. Drug withdrawal and Lewy body dementia.

c. Acute blood loss and frontotemporal dementia

d. Drugs and dementia.

5. True or false: Dementia is an inevitable consequence of

aging.

a. True.

b. False.

6. Dementia is often misdiagnosed as:

a. depression.

b. mild cognitive impairment.

c. Alzheimer’s disease.

d. anxiety.


7. Use physical restraints with patients who have dementia or

delirium:

a. if the patient is agitated or confused.

b. when there is a significant risk for a fall.

c. if all other interventions fail and there is a serious risk of harm.

d. if the patient is likely to wander.

8. Neuropsychiatric behavior problems in patients who have

dementia:

a. are caused by an external or internal stimulus.

b. typically occur randomly and without cause.

c. only occur if patients are over-medicated.

d. happen primarily at night.

9. The use of anti-psychotics to treat patients with dementia:

a. is considered first-line therapy.

b. is most effective when used in conjunction with cholinesterase

inhibitors.

c. can reverse the progress of dementia.

d. is questionably effective and potentially dangerous

10. The drug most commonly used to treat agitation in patients

who have delirium is:

a. diazepam.

b. haloperidol.

c. galantamine.

d. bupropion.


CORRECT ANSWERS:

Footnotes:

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Clinical Geriatrics. 7th ed. New York, NY: McGraw-Hill; 2013. Online edition, retrieved

September 25, 2014 from www.UCHC.edu.

2. Alagiakrishnan K. Delirium. eMedicine. April 28, 2014. Retrieved September 25,

2014 from

http://emedicine.medscape.com/article/288890-overview#aw2aab6b2b4aa.

3. Seeley WW, Miller BL. Dementia. In: Longo DL, Fauci AS, Kasper DL, Hauser SL,

Jameson JL, Loscalzo J, eds. Harrison’s Prinicples of Internal Medicine, 18th ed. New

York, NY: McGraw-Hill; 2012. Online edition, retrieved September 25, 2014 from

www.UCHC.edu.

4. Centers for Disease Control and Prevention. Alzheimer’s Disease. July 25, 2104.

Retrieved September 25, 2014 from

http://www.cdc.gov/aging/aginginfo/alzheimers.htm.

5. Shadlen MF, Larson EB. Evaluation of cognitive impairment and dementia.

UpToDate. February 12, 2014. Retrieved September 27, 2014

fromhttp://www.uptodate.com/contents/evaluation-of-cognitive-impairment-and-

dementia?source=search_result&search=dementia&selectedTitle=1%7E150.

6. Josephson SA, Miller BL. Confusion and delirium. In: In: Longo DL, Fauci AS,

Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Prinicples of Internal

1. A

2. C

3. B

4. D

5. B

6. A

7. C

8. A

9. D

10. B

http://www.uchc.edu/

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http://www.cdc.gov/aging/aginginfo/alzheimers.htm

http://www.uptodate.com/contents/evaluation-of-cognitive-impairment-and-dementia?source=search_result&search=dementia&selectedTitle=1%7E150

http://www.uptodate.com/contents/evaluation-of-cognitive-impairment-and-dementia?source=search_result&search=dementia&selectedTitle=1%7E150


Medicine, 18th ed. New York, NY: McGraw-Hill; 2012. Online edition, retrieved

September 25, 2014 from www.UCHC.edu.

7. American Psychiatric Association. Neurocognitive disorders: Major and mild

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ed. Arlington, VA: American Psychiatric Publishing; 2013. Online edition, retrieved

September 25, 2014 from www.UCHC.edu

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from www. UCHC.edu.

9. Francis J. Delirium and acute confusional states: Prevention, treatment, and

prognosis. UpToDate. August 13, 2o14. Retrieved September 27, 2014 from

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prevention-treatment-and-

prognosis?source=search_result&search=Delirium+and+acute+confusional&selected

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12. McDade EN, Petersen RN. Mild cognitive impairment: epidemiology, pathology,

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from

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DELIRIUM & DEMENTIA - NurseCe4Less.com · Dementia and delirium are the major causes of cognitive...

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Transcript of DELIRIUM & DEMENTIA - NurseCe4Less.com · Dementia and delirium are the major causes of cognitive...